RO INSLER TAEKWONDO – SUMMER REGISTRATION FORM Date ____________

Last Name________________________________ First Name _____________________________ Date of Birth_______________

Address_________________________________________________________________________

Town________________________ State____ Zip________ Home Tel #______________________

[Parent’s Full Names ___________________________________________________] Bus. Tel # ___________________________

Emergency Contact _________________________________ Tel # _____________________ Relationship to Student_________________

Doctor's Name__________________________________ Tel # _______________________

Medical Conditions/Medications (if any) _________________________________________________

Medications (if any) ________________________________________________________________

Course #: - Day(s): - Time: pm – Class:________________________________________- Fee: $ .

NO REFUNDS OR CREDITS AFTER SESSION HAS BEGUN. Less Family Disc. (if any) -_________

School Use Only: _____________________________________ Total Fee Enclosed $__________

Make checks payable to / bring to RO INSLER TAEKWONDO